1. Complications and Benefits of Bariatric Surgery
Tracy Robinson
PAS 646
Advisor: Dr. Hadley

2. Objectives Obesity Statistics Bariatric Surgery options
Post-surgical complicatioins
Nutritional consequences
Improvements in co-morbidities
Psychological and QOL improvements
Why do PAs need to be aware?

3. Obesity Statistics 33% US population is obese (BMI ≥ 30 kg/m2)
8 million people in US morbidly obese (BMI ≥ 40 kg/m2)
Between 1986 and 2000……
Obesity doubled
Morbid obesity quadrupled
Super obesity (BMI ≥ 50 kg/m2) increased five-fold

4. Obesity Statistics cont…..
Men > 50% overweight = double mortality
Men > 50% overweight + DM = 5x mortality
Women > 50% overweight = 2x mortality
Women > 50% overweight + DM = 8x mortality
5% total healthcare costs
US $60 billion

5. Bariatric Surgery 1990 – 2000 → 4925 to 41,000 2005 → 130,000
2010 → 218,000
Bariatric surgery criteria
BMI ≥ 40 kg/m2 without co-morbid disease
BMI ≥ 35 kg/m2 with concurrent co-morbid disease

6. Roux-en-Y Gastric Bypass
15 to 25 ml gastric pouch with 1 cm outlet
Bypass distal stomach, duodenum, first segment of jejunum
Bypass cm jejunum
65% -70% EBW loss
Decrease BMI 35%
images/bg_roux2.gif

7. www.weighlite.com/images/ content/gastric-diag.jpg
LAP-BAND
No physiological changes or resections
Band around upper stomach creates 15 ml pouch
Port of adjustment attached to abdominal wall
Inflate/deflate 6 times a year
50% EBW loss
content/gastric-diag.jpg

8. Post-surgical Complications
Anastomosis leaks or staple line leaks
PE or DVT
Cholelithiasis
Stomal ulceration
Dumping syndrome
Constipation

9. Anastamosis Leaks Up to 7-10 days after surgery
Most common at gastrojejunostomy, enteroenterostomy, Roux limb stump, staple line
Can lead to peritonitis, sepsis, possible death
Presentation
Tachycardia, tachypnea
Fever
Ab pain/back pain
Pelvic pressure or rebound tenderness

10. Anastamosis Leaks Order Gastrograffin upper GI series
Subclinical cases
Bowel rest
Parenteral nutrition
IV antibiotic if H. pylori
Clinically suspect leak
Laparoscopic evaluation and leak repair
Failure to evaluate is the most common cause of preventable, major long-term disability or death in bariatric surgical patients

11. Pulmonary Embolism Sudden cause of death up to one month after surgery
20%-30% mortality rate
High risk may have vena cava filter placement prior to surgery
Prophylaxis with compression stockings and LMWH
Early ambulation imperitive

12. Pulmonary Embolism Presentation Immediate spiral chest CT
Profound hypoxia
Hypotension
Signs of sepsis
Immediate spiral chest CT
Abdominal exploration if too large for machine
No pathology start anticoagulation
Too large…….NO SURGERY

13. Cholelithiasis Up to 36% of patients within 6 months post-op
Bile stasis leads to increased sludge and gallstones
Prophylactic cholecystectomy prior to surgery if evidence of existing sludge or stones
Prevent post-operative disease with concurrent bariatric surgery and cholecystectomy
Prophylactic use of urosidol
Expensive and unpalatable

14. Stomal Ulceration 12%-15% within 2-4 mos. Post-surgery Etiology
Overabundant acid in pouch leads to excessive acid passing through stoma
Pouch tension and staple line breakdown
NSAID use
Presentation
Dyspepsia, vomiting
Epigastric or retrosternal pain

15. Stomal Ulceration Treatment If no response to treatment PPI, carafate
Antibiotics if H. Pylori
Avoid NSAIDS, alcohol, smoking
If no response to treatment
Endoscopy
Back to surgery for pouch revision or staple line repair

16. Dumping Syndrome More than 15% patients Hypotention Tachycardia
Lightheadedness, syncope
Flushing
Abdominal cramping and diarrhea
Nausea and vomiting

17. Dumping Syndrome Occurs with high dose simple sugar ingestion
Sugar in small intestine causes osmotic overload and fluid shift from blood to intestine
Increased intestinal volume leads to watery diarrhea
Decreased blood volume leads to systemic changes
Patient education
Eat slowly
Avoid drinking before, during and not until 30 minutes after meals.

18. Constipation Most common complaint Causes
Dehydration and decreased fluid intake post-operatively
Increased metabolic water needs
Calcium and iron supplement use following surgery
Treat with increased fluids and stool softeners

19. Nutritional Consequences
Iron deficiency anemia
B12 deficiency
Folate deficiency
Calcium and Vitamin D deficiency
Not seen with purely restrictive surgeries

20. Iron deficiency and anemia
Common following RYGB
As high as 49% of patients
Multifactorial cause
Low gastric acid levels prohibit iron cleavage from food
Absorption inhibited because no nutrient exposure to duodenum or proximal jejunum
Decrease in iron-rich food consumption due to intolerance
Treat with oral supplementation of ferrous sulfate or ferrous gluconate

21. Vitamin B12 deficiency Up to 70% of patients
Lack of hydrochloric acid and pepsin in stomach
Prevents B12 cleavage from food
Affects secretion of intrinsic factor, thus B12 absorption
Intolerance to meat and milk
Oral supplementation usually adequate, otherwise, IM injections used

22. Folate Deficiency 40% of gastric bypass patients
Complete absorption requires B12
Absorption dependent on HCl and upper 1/3 stomach
Deficiency generally caused by decreased consumption
Oral supplementation

23. Vitamin D and Calcium Deficiency
Vitamin D deficiency is common among obese people
Calcium absorption decreased because duodenum is bypassed
Intolerance to dairy, foods high in calcium
Vitamin D is required for Ca++ absorption
Prolonged deficiencies lead to
Bone resorption, osteomalacia, osteoporosis
Treat with calcium citrate supplementation and 2 weekly doses of Vitamin D

24. Improvements of Co-morbidities
Type 2 diabetes mellitus
Hypertension
Hyperlipidemia
Degenerative joint disease
Sleep apnea
GERD
5% to 10% weight reduction is associated with significant decrease in risk
Weight loss from surgery reduces or eliminates medications
Improves severity or resolves co-morbid disease

25. Improvements of Co-morbidities
2 years after surgery diabetes mellitus was resolved in 83% of pre-operative diabetic patients (Sugerman et. al 2005)
2 years following surgery 69% had resolution of hypertension
8 years post-surgery there was complete relapse in those with gastric banding
25% decrease in total cholesterol and 40% decrease in triglycerides 6 to 12 months after surgery

26. Psychological and Psychosocial Improvements
Depression
Low self-esteem and self-appraisal
Poor interpersonal relationships
Feelings of failure and dissatifaction with life
Subject to prejudice and discrimination

27. Psychological and Psychosocial Improvements
“ Most obese patients consider impaired QOL the most crippling aspect of their disease, and after surgery consider enhanced QOL the greatest benefit” (Puzziferri 2005).
“Obese individuals would rather have a normal weight with a severe disability such as be deaf, have heart disease, have an amputation and others rather than be obese without any of these conditions” (Livingston 2003).

28. Psychological and Psychosocial Improvements
Significant improvement in QOL with all types of surgery
New vocational and social activities
Improved interpersonal relationships
Better moods, self-esteem
More employable, get paid more, work more and take less sick days.

29. Why do PAs need to know this?
We will be the long-term healthcare provider
Consequences and complications last a lifetime
Initial provider assessing signs and symptoms
Track improvements
Medication changes
Stay educated in all specific needs and concerns of bariatric surgery patient!